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Are We Doing Too Many TKRs?

Two recent reports raise concerns regarding total knee replacement (TKR), one of most successful advances in orthopedic surgery in the last 30 years. An article in JAMA by Cram and colleagues,1 cites a 161% and 106% increase in primary and revision TKRs, respectively, in Medicare patients during this 20-year period. "The growth in [total knee arthroplasty] should prompt consideration of whether too many (or too few) of these procedures are being performed," the authors stated.

Furthermore, an announcement in MLN Matters,2 a Medicare website for healthcare professionals, advises how to "avoid denials of claims for major joint replacement surgery" by ensuring that the medical record contains "enough detailed information to support that major joint replacement surgery is reasonable and necessary for the patient." In the past year, reports have described denials of Medicare payments to surgeons and hospitals for patients undergoing TKR with inadequate documentation in the medical record that the procedure was medically necessary.

Is TKR under attack by data analysts and federal agencies? I think not, and here is why.

The fact that the actual number as well as per capita usage of primary and revision TKR have nearly tripled between 1991 and 2010 can be accounted for by many factors, that Cram and colleagues1 appropriately list: increased number of candidate for TKR due to the aging baby boomer generation, an aging population with more comorbidities including obesity and diabetes, and expanding indications for the procedure as implant design and surgical techniques have improved over the past 20 years. We certainly should not assume that the increase in number of TKRs during this period necessarily implies overuse of this procedure. Improvements in design and techniques have increased utilization of technology in other fields as well during this period. For example, the number of computers used in the United States has increased exponentially from 1991 until 2010. We clearly do not overuse computers!

Nevertheless, Cram and colleagues rightly question whether the growth in TKR utilization represents "over-use of a highly reimbursed procedure for which indications still depend on clinical judgment." From my perspective, overuse implies surgical treatment with inappropriate indications. As a profession, we orthopedic surgeons should embrace such a challenge head on and clearly define and document indications for knee replacement surgery as we do for any operative procedure. In fact, the documentation of appropriate indications for joint replacement is exactly what the MLN Matters announcement addresses.

Medicare has begun to deny payments to hospitals and surgeons if the medical record inadequately documents the necessity for hip and knee replacement surgery. This issue can be easily resolved if surgeons take the necessary and reasonable steps to document the indications for surgical intervention, namely, disabling pain and limited function unresponsive to a thorough nonoperative treatment program with physical exam findings and radiographic evidence of end-stage degenerative joint disease. These are fundamental surgical principles that we learned during the course of our orthopedic residencies and fellowships. I do not believe that it should be considered a burden for orthopedic surgeons to adequately document the medical necessity of an operative procedure.

TKR utilization has increased enormously over the past 20 years and has benefited millions of our patients. There are many legitimate and understandable reasons to account for this increase. As the number (and costs!) of TKRs has increased, it is perfectly reasonable and appropriate to insure that these major surgical procedures are, in fact, indicated. We orthopedic surgeons should welcome transparency and scrutiny by independent analysts and, even better, orthopedic peer review, to confirm that TKRs are, indeed, indicated in all our patients. Such practice would obviate any implication of overuse of one of the most beneficial procedures in orthopedic surgery and serve as a model for true healthcare reform, whose goal should be not to ration medical care but, initially, to simply eliminate inappropriate treatment that offers no benefit to our patients.

Author's Disclosure: The author reports no actual or potential conflicts of interest in relation to this article.

Am J Orthop. 2012;41(11):491,499.

1. Cram P, Lu X, Kates SL, Singh JA, Li Y, Wolf BR. Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, 1991-2010. JAMA. 2012;308(12):1227-1236. 2. Department of Health and Human Services, Centers for Medicare & Medicare Services. Documenting Medical Necessity for Major Joint Replacement (Hip & Knee). MLN Matters. September 18, 2012. http://www. Learning-Network-MLN/MLNMattersArticles/ Downloads/SE1236.pdf. Accessed October 11, 2012.

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